Lorry talks with Ian Rummery the Prison and Offender Management Nurse for HMP (Her Majesty’s Prison) Jamestown on the remote island of St Helena in the South Atlantic Ocean. Ian is a transplant to the island from Australia and also works as a Community Psychiatric Nurse with the population there. It was through his mental health work that brought him into the prison about 10 years ago.

As you can see from the map below, St. Helena island is off the coast of southwest Africa and is a British territory.

Here are some pictures of HMP Jamestown Prison to help you get an idea of the situation. The island is mostly volcanic rock with the population of 4500 mainly situated in the capital of Jamestown on the northeastern shore.

The prison was built in 1827 and looks much as it did over 150 years ago. Here is the receiving area. Up the stairs are the cells and down the stairs is the medical unit.

Ian describes his practice along with surprises and challenges in the podcast. He has 13-14 patients at any one time and his practice in the prison is structured for 3 days a week, although he is sometimes there longer depending on need. Here is the medical unit at HMP Jamestown.

What did you find interesting or surprising about correctional nursing on St. Helena? Share your thoughts in the comments section of this post.

The Food and Drug Administration (FDA) has added a Black Box Warning to new Hepatitis C pharmaceuticals as reports mount of flare-ups of Hepatitis B in those patients receiving the drugs. Gilead’s Sovaldi is one such medication. More information is needed but this side effect is likely to complicate Hepatitis C treatment in correctional settings as many patients are co-infected.

Cheeking is the practice of hiding drugs in the mouth for later use rather than swallowing them when administered. It is a concerning practice by some of our correctional patients. Dr. Jeff Keller identifies several ways our patient’s commonly divert drugs such as palming them and pretending to take them, or hiding them in denture adhesive or empty tooth socket. The unusual case he describes in this article is a known drug diverter whose meds were crushed but he was somehow able to keep the powder on his tongue and later turn it into a spit wad. Dr. Keller states in this piece that “a good correctional nurse will usually catch such attempts” (referring to the more common methods). Panelists discuss various cheeking methods and the role of correctional nurses and custody officers in preventing medication diversion.

The New Hampshire prison system is the only state where their Secure Psychiatric Unit (SPU) is not only used for convicted mentally ill patients but also hard-to-handle mental health patients who have not committed a crime. The SPU is a 65-bed unit and five to ten patients at any given time are from the outside. There is growing concern about this practice.

Research in two prisons in Oregon indicate that transcendental meditation can reduce anxiety, depression, and sleep disturbances for prisoners. This was an experimental study with a meditation group and a control group of non-meditating inmates. The experimental group had four months of the intervention while the control group participated in all other standard care but did not practice meditation. This non-pharmacologic treatment shows promise for improving prisoner mental health.

Share your thoughts on these news stories in the comments section of this post.

Robert D. Canning, Ph.D., CCHP, is Sr. Psychologist Specialist, Quality Management Program, Statewide Mental Health Program for California Correctional Health Care Services. This post is based on his session “Self-injury: Public Health Surveillance for Quality Improvement” taking place at the 2016 National Conference on Correctional Health Care in Las Vegas, October 22-26, 2016.

Self-injury is a growing concern in correctional health care practice. Self-injury (also called self-harm) is behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. The Quality Management Program of the Statewide Mental Health Program for the California Correctional Health Care Services (CCHCS) has been systematically counting and classifying self-harm events in California prisons for about 2 1/2 years. Over that time there have been over 5,000 self-injury events; indicating that the rate of self-harm for this prison population at 2.3%. While this is low for a prison population, one systematic review found over 20% of prisoners self-harm at some time during incarceration, this is still a high number of incidents that need addressed.

Published numbers of non-suicidal self-injury (NSSI) are higher among those in solitary confinement, youth, and females. In the CCHCS study, overall self-injury for men was 2.0% and for women 7.3%. Sixty-one percent of self-harm incidents were not suicidal in nature and involved little medical injury.

Interesting findings from the CCHCS study included a better understanding off the magnitude of costs associated with self-harm, particularly those incidents that require more significant medical intervention; particularly hospital treatment. Of the self-harm events counted in the past two years, almost one-quarter of them (1,263) have resulted in outside hospital stays, with a range of one to 124 days. Seventy-one percent of those have been for one day or less – typically an emergency department visit with return to the prison within hours.

CCHCS self-harm surveillance is a part of their suicide prevention program that has been around for two decades. They have found that a population-based approach is best in assessing and managing this condition.

Results of the quality initiative are currently locally-based with predominantly individual prison facility projects. For example, CCHCS is in the early stages of establishing a specialized treatment unit in one prison that will deliver Dialectical Behavior Therapy, an evidenced-based treatment for suicidal and self-harming individuals.

In addition, the CCHCS medical informatics group has been working to develop an “early warning system” for suicide attempts using machine learning algorithms. They are currently preparing a multi-year grant proposal to the American Foundation for Suicide Prevention to refine the system and make it clinically useful. This project has promise to reduce rates of suicide and self-harm in CDCR and elsewhere.

Do you have patients that self-harm? Share your experience in the comments section of this post.

Vinneth Carvalho MD, Assistant Chief of Psychiatry at the University of Connecticut-Correctional Managed Health Care, and Amy B. Smoyer, PhD, Assistant Professor, Department of Social Work, Southern Connecticut State University in New Haven, CT join Lorry to discuss the importance of food for physical and psychosocial health. They are presenting a session on “Why Food Matters: Physical and Psychosocial Health of Incarcerated Women” at the 2016 National Conference on Correctional Health Care.

Food is a central part of prison life; all life, actually. As humans, food is used to construct identity and relationships, power, control, and even gender perceptions.

In addition, food consumption can be a critical predictor of physical health. Undereating or overeating causes long-term consequences. Obesity, in particular, can lead to diabetes, cardiovascular disease, hypertension, and cancers.

Formal and Informal Food Settings

The formal food system in a correctional setting is usually a chow hall or scheduled meal delivery to a housing unit. The informal food system might be food obtained from the commissary or sharing food among the inmates. Money to buy food can be an issue for many. For example, money sent from the outside for obtaining food can mean that the incarcerated person is not forgotten; that someone cares. Lack of money to purchase food can be demoralizing or lead to bartering services or personal items for food from other inmates.

Inmates who work in the kitchen are also part of the informal food network. Some smuggle food from their worksite for cooking or sharing in the housing unit. Inmates often build relationships through these informal means.

Obesity

Most inmates are likely to gain weight while in prison. Studies show that incarcerated women, in particular, tend to gain weight behind bars. Factors encouraging weight gain include:

Limited movement – sedentary lifestyle in prison

Meal size, especially for women

Unhealthy commissary options – especially reasonably priced ones

Psychotropic medications – especially 2nd generation

Fewer work release options for women

Substance use recovery – food can replace drugs or alcohol as a brain reward.

Food Allergies

The identification of true food allergies can be difficult in the correctional setting. Patients can confuse food preferences with food allergies. The most common food allergies are dairy, nuts, shellfish, and soy. A full patient history and validations of allergic response is needed. Verification in the community is also helpful. Communication with the kitchen staff is then needed so that appropriate measures are taken. Indigestion, gastric reflux, and other GI issues may be described as a food allergy and should be investigated.

How is food managed in your setting? Share your thoughts in the comments section of this post.

Deborah Ash, RN-MSN, MBA, LNC, CCHP is Vice President of Compliance for Advanced Correctional Healthcare in Peoria IL. This post is based on her session“Ethical Boundaries: What Nurses Need to Know”taking place at the 2016 National Conference on Correctional Health Care in Las Vegas, October 22-26, 2016. Learn more about the conference and registerHERE.

Ethical nursing practice is a priority in all specialties, but nurses working in corrections can find themselves in situations that were never discussed in nursing school. These situations require that we apply foundational ethical principles in a whole new way. Avoiding ethical boundary crossing in this setting can feel like walking a tightrope over a shark tank.

What is an Ethical Boundary?

In many ways, an ethical boundary is the limit to which we can be professionally involved with our patients. That boundary is crossed when we enter into a personal relationship or do ‘favors’ for our patients that may not be appropriate in our setting.

In traditional patient care settings, it may be perfectly natural to talk about family in conversation with patients or to help a patient with non-patient-care issues like addressing a card or making a phone contact. The restricted nature of a secure setting, however, makes these patient-helping situations out-of-bounds – and even illegal. Correctional nurses must be well-versed in the security regulations of their setting.

Correctional People and Places

The correctional setting can be very different from other nursing practice settings. There is often less nursing structure and practice is autonomous. Correctional nurses must be willing to speak up when asked to participate in ethically questionable activities. This requires assertiveness and a good relationship with leadership and correctional colleagues.

Our caring nature can come into conflict with security and safety regulations. Simple gestures such as mailing a letter for a patient or providing items from the outside world may seem innocent kindnesses but can put everyone’s safety in jeopardy.

Some incarcerated patients will take advantage of the caring nature of health care staff for their own benefit. Nurses new to corrections can get in hot water if they continue to practice in a fully trusting mode without objectively validating patient symptoms and requests.

Does and Don’ts of Boundary Crossing

Here are some pointers to stay within professional nursing practice boundaries in corrections.

Know your practice setting: Gain an understanding of the particular correctional environment in which you work. What are the key boundary crossing issues? For example, nurses working with adult sex offenders will have different issues than those working in a juvenile detention center.

Follow the rules: Know and follow all security rules, particularly in the areas of what can be done for your patients. For examples, most settings do not allow staff to exchange objects or communications with inmates. You cannot mail letters or bring in favorite foods for inmates.

Relationships matter: Have a good relationship with officer colleagues. Ask them about a situation if you are unclear.

Firm, fair, consistent: Treat every patient similarly. No patient should be given favorite or preferential treatment.

Know your patient: Be aware of common manipulation techniques. Find out more here and here.

Know your environment: Always be aware of your surroundings.

Take care of each other: Watch out for your fellow workmates in their patient relationships. Sometimes an outsider may be able to see the change in a patient relationship that could spell trouble.

What ethical boundaries are challenging you in correctional nursing practice? Share your experience in the comments section of this post.

Mitzi Peterson, MSW, LICSW, CCHP, and Michael Beauchemin, MA, work for Massachusetts Department of Correction. This post is based on their session“Management of Insertion and Self-Embedding Behaviors”taking place at the 2016 National Conference on Correctional Health Care in Las Vegas, October 22-26, 2016. Learn more about the conference and registerHERE.

A 32 year old white male is brought to the medical unit with a pen embedded in his right forearm. During the initial assessment he tells the nurse he inserted it himself and is hoping to be transferred to the protective mental health unit. The arm is swollen and may be infected. The nurse practitioner on shift works with the nurse to remove the pen, clean and stitch the wound, and start antibiotic treatment. A mental health evaluation is scheduled.

The Massachusetts Department of Corrections (MADOC) has seen a significant increase in insertion and self-embedding behaviors among the behaviorally challenging and the mentally ill. In 2015, 11 inmates used this behavior in 25 incidents. In addition, 49 incidents of insertion or self-embedding occurred in the state hospital run by MADOC. Some inmates appear to use these behaviors in an attempt to obtain pain medications while others appear to be less goal-directed and are seeking psychological relief.

When patients insert or self-embed, they are not attempting suicide but are trying to injure themselves. Insertion involves the placement of foreign bodies into the urethra, anus, vagina, or other body orifice. Similarly, self-embedding involves placing foreign objects into the soft tissues of the body. Disturbed individuals use these behaviors in response to internal and external stressors. The cause is unclear but is often linked to such conditions as PTSD, Borderline Personality Disorder and Anti-Social Personality Disorder. In the example above, the inmate had a strong motivation to be transferred to a different location in the prison. The stressors of his current location moved him to take an extreme action.

Management of Insertion and Embedding Behaviors

Management of inserters/self-embedders is challenging and requires an individualized approach. Here are key concepts in treatment plan development.

Determining the person’s goal in using the behavior is critical in order to best devise a response and recovery plan.

Behavior management plans with incentives that reduce self-injury behaviors and use practical devices to prevent impulsive behaviors have been effective.

Communication between all providers is imperative in order to provide a consistent response to the behavior and to avoid potential rewarding of dangerous self-injury.

When possible, referral to a Residential Treatment Unit is made in order to place the inmate in a therapeutic milieu for ongoing treatment and monitoring.

Challenges of Management

Here are some of the challenges encountered by the MADOC when working to manage the increasing incidents of inserting and self-embedding behaviors.

Identification of the behavior is the first challenge as it requires self-disclosure. This often happens when medical involvement is necessary, as in the example above.

In addition, it is very challenging to restrict access to items that can be inserted or imbedded. Inmates and patients are very skilled at using items which correctional professionals have yet to consider.

Once the self-injury has occurred, it can be a challenge to understand the cause that resulted in the behavior.

Medical care for the removal of or management of an inserted or embedded item requires significant monitoring in an environment of potential infection.

The Future of Self-Injury Treatment

Correctional systems must work together to collect data about what is working, what is not working and what our next steps should be when faced with these complicated forms of self-injurious behaviors. Intent and motivation are key variables which we should all be assessing in order to build a knowledge base for future intervention building.

Have you cared for a self-injuring patient? Share your experience in the comments section of this post.

The state of Nebraska agreed to settle a civil rights lawsuit filed by an inmate who claimed that the state prison’s medical director refused to provide hormone therapy for a gender identity disorder. The article quotes the US Department of Justice’s policy guide as saying that denying inmates with gender dysphoria the ability to fully adopt a gender role that matches their gender identity can constitute a denial of necessary medical care and, therefore, be in violation of the inmate’s constitutional rights. Things are moving fast throughout society regarding transgender issues. Panelists share their experiences and insights.

Word from the Mississippi State Penitentiary, also called Parchman, that one of their largest kitchens was shut down due to health violations. Pictures from the article show evidence of rodents, leaking ceilings, and unclean conditions. Parchman is the state’s oldest Institution, opening in 1901. It is located on approximately 18,000 acres and has a capacity of approximately 3,590 beds. Health violations in an old prison kitchen in Mississippi is a symptom of just one of the health issues involved in housing inmates in run down facilities far from much of civilization. Panelists discuss the health concerns of the correctional environment.

The inmate underground is where items of value are exchanged for services. In this barter system, common currency includes cigarettes, cell phones or medications. But a sociology study out of the University of Arizona is suggesting that Raman noodles are gaining ascendency in the prison barter culture.

This story highlights the work of Ontario County Jail nurse, Joan Mitchell, and her work in the New York Jail. The article was initiated by her recent certification as a CCHP-RN which is the nurse-specific certification for Correctional Health Professionals.

What are your thoughts on these news stories? Share your insights in the comments section of this post.

Patricia Blair, PhD, LLM, JD, MSN, CCHP-A is a nurse attorney practicing in Texas. She serves as the American Bar Association representative on the National Commission on Correctional Health Care Board of Directors and frequently writes and speaks on ethical, legal, and policy issues in healthcare. She will be speaking on legal and ethical issues for correctional nurses at the 2016 National Conference on Correctional Health Care.

Correctional nurses are particularly vulnerable to legal and ethical issues due to the added concerns of constitutional rights and the need to meet community standards of healthcare in a challenging setting. The complexity of delivering health care in a secure setting combined with the need to meet security policy and procedure also contribute to these issues. According to her extensive experience, Dr. Blair suggests the following legal and ethical issues of highest concern in correctional nursing practice.

Top Legal Issues

Indifference Standards: Nurses working in correctional settings must be aware of the civil rights implications of health care. Constitutional law has established that lack of adequate health care while incarcerated is an abridgement of the Eighth Amendment to the Constitution for sentenced inmates and the Fourteenth Amendment to the Constitution for detainees. Nurses are legally bound to provide necessary health care and to avoid being deliberately indifferent to incarcerated patient needs.

Scope of Practice: Budget constraints and isolation from the traditional health care system can lead to nursing practices that are beyond the scope of licensure. Dr. Blair is particularly concerned with the increased use of LPN/LVN nurses in place of registered nurses as they can be placed in positions beyond their education or knowledge.

Privacy and Confidentiality: Security and safety needs often require health care to be delivered in the presence of officers. The privacy and confidentiality of health information can be jeopardized in these situations.

Top Ethical Issues

Respect of the Patient: Respect for human dignity is challenging in a setting where all your patients have been sentenced or are detained for criminal behavior. Yet, most nurses are unaware of patient criminal history in traditional settings. As correctional nurses it is important to lay aside any criminal information about a patient and respond to them based on their inherent human dignity as an individual.

Patient Advocacy: Facility structure and standard operating procedure can thwart efforts to get incarcerated patients the health care they need. Sometimes the barriers lead to nurses not following through in their advocacy efforts, such as going through the chain of command when peer collaboration fails.

Accountability: Nurses are accountable for providing adequate care when on duty. Correctional nurses can be required to have a broad array of skills in order to meet patient needs in a particular secure setting. Thus we must be acutely aware of personal practice strengths and weaknesses. Correctional nurses are accountable for the necessary knowledge and skills for the setting of employment. This may mean developing new skills and acquiring new knowledge.

What do you think are the top legal and ethical issues you face in correctional practice? Share your thoughts in the comments section of this post.

Want to hear directly from Patricia and also other correctional healthcare leaders from across the country? Click here to register for the 2016 National Conference on Correctional Health Care in Las Vegas.

Fran Tompkins RN, MS, CCHP-RN, CCN/M, is Nursing Training and Education Supervisor with Correct Care Solutions, Nashville, TN. This post is based on her session“Critical Thinking: Best Practices for Best Results”taking place at the 2016 National Conference on Correctional Health Care in Las Vegas, October 22-26, 2016. Learn more about the conference and registerHERE.

Critical Thinking is “…the disciplined intellectual process of applying skillful reasoning as a guide to belief or action.”

-Paul, Ellis and Norris

The correctional environment and patient population can lead to imbalanced thinking just when we need to be clear-headed. Biases in our mental process, both conscious and unconscious, can derail our efforts to critically appraise a clinical situation. For example, a middle-aged patient complains of chest pain for the 3rd time in 2 weeks. The previous times he had a complete work-up that showed no cardiac disease. The housing officer tells you this guy had no signs of distress and she thinks he is faking ‘again’…and there is a long line of patients waiting for sick call. What to do?

Short Cuts – Good and Bad

Cognitive short cuts help us reach conclusions or decisions quickly. Driving is an example: when we drive automatically, we can conserve cognitive energy for alternative uses. The problem arises when something out of the ordinary happens and we are caught without being prepared: a blowout, or someone changes lanes into our lane without looking. Now we are placed in a reactive situation: trying to problem solve without preparation.

We place ourselves in automatic drive every day when we recognize common patterns of patient behaviors and assessments. Cognitive shortcuts can help us quickly put the puzzle together to rule out appendicitis or recognize early signs of alcohol withdrawal.

Unfortunately, we can just as easily take mental short cuts that short circuit good clinical judgment. Errors are not caused by not knowing, but by the well-intentioned efforts of hard working people in imperfect systems using flawed thinking. It’s not that we do not KNOW, it’s how we THINK about our patients that gets us into trouble. Deciding that the patient with chest pain is feigning illness based on past experiences and the officer’s evaluation can spell trouble.

Best Practice Tips

Using each other for reference points. Bounce your theories off fellow staff members. Ask questions like “What do you think about this patient?” or “What have I missed?” can encourage deeper thinking. Even retroactively, these situations become learning opportunities.

Practicing reflective thinking and encouraging it in others. Debrief challenging situations and talk about what you were thinking and feeling during the event.

Encouraging each other to read, write, listen and speak critically. Use a worksheet for caregivers to objectively and constructively self-criticize their own thinking.

Discussing current cases and care decisions at staff meetings and during new staff orientation. Stories have been the best teaching methods since preschool. Start the conversation early, and keep it going!

Avoid labeling patients by their condition. Naming a patient by their diagnosis “the diabetic in A pod” or perceived adaptive behaviors “He’s a Momma’s boy” gets us into trouble by creating a lens we begin to use with all our patient encounters. .

What do you think about the challenges of critical thinking in correctional nursing practice? Share your experience in the comments section of this post.

Angela Lambing, MSN, ANPC, GNPC, is a Clinical Support Specialist with Bayer HealthCare. This post is based on her session “Hemophilia: What You Need to Know” taking place at the 2016 National Conference on Correctional Health Care in Las Vegas, October 22-26, 2016. Learn more about the conference and register HERE.

Jena, an RN working in a medium security state prison, is making sick call rounds. In housing unit C she is approached by an inmate in his late 30’s. He is barely able to hobble into the sick call room. He says he has hemophilia and is experiencing a bleed in his right ankle after having to walk with shackles for several hours earlier in the day. He also said he told those at intake two weeks ago that he had the condition and needed an infusion three times a week but no one has set him up with anything yet.

The 411 on Hemophilia

Hemophilia is an X-linked recessive bleeding disorder. Mothers carry the gene and pass on to their sons. This results in a bleeding disorder described as Hemophilia A (FVIII deficiency) or Hemophilia B (FIX deficiency). Severe hemophilia (<1% Factor level where the normal range is 50-100%) causes acute bleeding episodes, bleeding after injury, and spontaneous joint bleeding that leads to end-stage joint disease. The mainstay of therapy is replacement of the missing factor to raise levels to a near normal. This reduces bleeding risk.

A Common Inmate Condition?

While over 20,000 men are estimated to have hemophilia in the US, it is unclear how many incarcerated men have the condition. Given that this is a male-dominated disease and more inmates are male, it is expected that correctional nurses, like Jena, may encounter patients with the condition.

Hemophilia Issues Behind Bars

If you have a patient with hemophilia, they are likely to know more about the condition than you do. Take their lead about treatment and injury. This is a life-threatening condition that can need immediate attention. Here are a few important areas to consider for hemophilia patients.

Bleeding may not be objectively evident: Listening to the patient who states he is having a bleed, even though it might not be readily evident. If you wait until you see swelling, warmth, or pain, it may be too late. By then, blood is already in the joint, causing damage.

Treatment coordination: Develop a relationship with the patient’s primary provider who manages their hemophilia. As an expert in management of this disease, they are an excellent resource and liaison for treatment.

Security coordination: Hemophilia is an example of a medical condition that our officer colleagues need to know about. They need to be aware of the high potential for bleeding events from head injury or fights. Work details may need modified as repetitive motion can lead to joint bleeding.

Patient self-care: Treatment for this condition requires the replacement of the missing factor. This is given in an infusion by IV push. Patients are trained at an early age to start their own IVs, prepare the medication and give it to themselves IV push. Your patient may know the best veins to use or know their way around the equipment. On the other hand, our patient population is known to make poor health decisions. Some hemophilia patients may not be managing their condition well and, therefore, have severe joint disease from frequent bleeds.

High cost of treatment: Factor infusions are expensive. Work with the patient’s regular hemophilia infusion center to develop a cost-effective option for the 3-times-per-week infusions many with hemophilia require.

Jena had to fast track a solution for this inmate. She called for assistance and had him transported by stretcher to the prison infirmary. The prison medical director contacted the patient’s primary provider and arranged for an emergency transfer to the local hospital. The patient received factor infusions and was monitored for other bleeding such as intracranial bleeding. By the time he had returned to the prison, arrangements had been made for regular infusions and the Health Services Administrator had scheduled staff inservices on the condition.

National Resources

By the way, federally-funded hemophilia treatment centers are located in each state within the US. These centers are experts in management of the disease. General hematology/oncology practitioners may not be experts or have the latest and greatest information related to this condition. You can find the nearest hemophilia treatment center (HTC) by visiting this site and typing in your city or state.

Do you have patients with hemophilia? Share your experience in the comments section of this post.